History Taking

Question 1

Abdominal Pain History

Answer 1

WIPER - wash hands, introduce, patient permission and process

PC:

SOCRATES (Site, Onset, Character, Radiation, Associations, Temporal Pattern, Alleviation/ Exacerbation, Severity)

Character - Colicky, Constant, Sharp, Dull

Radiation - Loin to groin, Through to back, Shoulder Tips, Scapula

Associations - Vomiting, Nausea, Sweating, Dyspepsia, Diarrhoea, Menstruation, Pregnancy, Jaundice, Alcohol, Drugs

Alleviating/Exacerbating - Eating, lying still, moving, urinating,

Always ask - Haematemisis, PR Bleeding, PR Mucous, Altered Bowel Habit, Chance of pregnancy, Anyone else unwell

FLAWS Fever, Lethargy, Loss of appetite, Weight Loss.

PMH - IBD, IBS, Surgery,

DH - Any allergies. Specifically ask about anticoagulation

FH - Relevant - IBD/ Cancers

SH - Occupation. Smoking. Alcohol. Drug use.

Mobility. Home - who lives with them

Systems Review

Summarise

ICE

Question 2

US Findings of cholecystitis

Answer 2

Thick Walled Gall Bladder >4mm

Pericholecystic Fluid

Gallstones

Question 3

i) Abdominal Pain onset hours after a meal?

ii) Abdominal pain immediately after eating?

iii) Abdominal pain before eating that ceases after eating?

Answer 3

i) Biliary Colic

ii) Gastric Ulcer

iii) Duodenal Ulcer

Question 4

Chest Pain Causes / Ix

Answer 4

Cardiac - Central, heavy chest pain. Radiates to jaw/ Arm

Pleuritic - Sharp chest pain made worse by inspiration/ coughing.

Oesophagitis - Worse by eating.

MSK - Moving/ touch.

Ix - CXR, ECG, Blood Tests, ?ABG, Angiography, Echo, REspiratory Function Tests, CTPA

Question 5

i) NYHA risk of peri-operative MI

ii) Chance of peri-operative re-infarction with time

Answer 5

i) NYHA:

I - Angina with strenuous exertion

II - “” Moderate exertion

III - “” climbing one flight of stairs

IV - “” with any exertion

ii) Time after initial infarction

<3 weeks - 80%

3 weeks - 3 months - 20-30%

3-6 months - 5 - 15%

>6 months - <5%

Question 6

i) Differentials for sensorineural hearing loss

ii) Ix

Answer 6

i) Viral labyrinthitis

Malignant compression on CN VIII

Internal Accoustic Meatus Trauma

Meniere’s Disease

BPV

Presbycusis

i) Ix - Otoscopy, Audiology, MRI + Gad (intracranial) , CT (fractures)

Question 7

Dizziness Questions

Answer 7

Ear Ache

Ear Discharge

Tinnitus

Hearing Change

Head Injury

Neuro SR:

Seizures
LOC

Visual Change

Headaches

Paraesthesia

Weakness

Speach Disturbance

Question 8

Barium Swallow Appearance for Achalasia

Answer 8

Rat’s Tail Appearance

Achalasia:

Loss of myenteric plexus resulting in delayed relaxation of the lower oesophageal sphincter.

Dysphagia to fluids and solids equally.

Ix - Manography - delayed lower oesophageal relaxation, high resting pressure, reduced oesophageal peristalsis

Barium Swallow - Rat’s Tail Appearance

Question 9

Suggestive of?

i) Knee Locking

ii) Knee Giving way

iii) Stiffness worsens throughout day

iv) Stiffness improves throughout day

Answer 9

i) Locking - Meniscal Pathology

ii) Giving Way - Ligamentous pathology

iii) Stiffness worsens - osteoarthritis

iv) Stiffness improves - inflammatory arthritis

Question 10

X Ray findings for:

OA vs RA

Answer 10

Osteoarthritis:

Loss of joint space

Osteophytes

Subchondral sclerosis

Subchondral cysts

Inflammatory ARthritis:

Loss of joint space

Erosions

• *S**oft tissue swelling
• *S**oft bones (osteopenia)

Question 11

Osteoarthritis:

i) Pathology

ii) Features

iii) Mx

Answer 11

i) Articular Cartilage wear leading to loss of joint space leading to 2 sequalae:

• Inflammatory thickening of synovium and joint capsule
• rubbing together of bony components leading to sclerosis, osteophytes, and cysts

ii) Early Morning Stiffness

Pain worse on exercise and relieved by resting

Normal bloods/ autoimmune

Heberden’s - Distal interphalangeal

Bouchard’s - Proximal Interphalangeal

iii)

Conservative - Weight loss, exercise, heat application,

Medical - NSAIDS, Intra-articular steroid injection

Surgical - Arthroscopy/ arthrocentesis, Realignment Osteotomy, Joint replacement

Question 12

Complications of TKR

Answer 12

Immediate

Fracture

Vascular Injury

Tourniquet problems - Ischaemia, DVT, Post-removal haemorrhage, Tourniquet burns, Skin Necrosis

Early

Wound Dehiscence, Wound infection, Joint infection, Common peroneal nerve palsy, Fat embolus

Late

Prosthesis loosening, Periprosthetic fracture

Question 13

Complications of thyroidectom

Answer 13

Immediate

Thyroid Storm, Haemorrhage, Hoarseness (Recurrent Laryngeal Nerve) , Weak Voice (External Laryngeal nerve)

Early

Infection, Hypocalcaemia

Late

Hypothyroidism, Recurrence of original pathology (cancers)

Question 14

Differential Diagnosis for unilaterally enlarged tonsil

Answer 14

(Dependent on the timecourse but)

Squamous Cell Carcinoma of the tonsil

Lymphoma

Asymmetrical Tonsil

Tuberculosis

Tonsillitis

Quinsy Abscess

Question 15

i) Describe neck lymphatic levels

ii) Describe neck node dissections

Answer 15

i) I - VII

I Submental + submandibular

II Upper IJV (Skull base -> hyoid)

III Middle IJV (Hyoid -> Cricoid cartilage)

IV Lower IJV (Cricoid Cartilage -> Clavicle)

V Posterior Triangle

VI Anterior Sub- Hyoid (between carotid sheaths from hyoid to suprasternal notch)

VII Superior Mediastinum

ii) Neck Dissections

Radical- All Nodes, IJV, SCM + CN XI

Modified Radical - I-VI nodal groups removed but some structures retained

Selective - Not all nodal groups removed

Question 16

Impotence History?

Answer 16

Impotence History:

Able to get erection?

Early morning erection?

How many times a week are you trying?

Pain while ejaculating?

Vascular Qs?

Urological Qs?

Neurological Qs? (back pain, radiculopathic pain, neurological bladder/bowel questions)

Hormones? (Gynaecomastia, hair loss etc.)

Mental Health?